Provider Demographics
NPI:1467460865
Name:ROZENBERG, ILYA (MS/CRNP)
Entity Type:Individual
Prefix:MR
First Name:ILYA
Middle Name:
Last Name:ROZENBERG
Suffix:
Gender:M
Credentials:MS/CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MARCIE WOODS CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1965
Mailing Address - Country:US
Mailing Address - Phone:410-766-1544
Mailing Address - Fax:410-766-1551
Practice Address - Street 1:7452 BALTIMORE ANNAPOLIS BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3547
Practice Address - Country:US
Practice Address - Phone:410-766-1544
Practice Address - Fax:410-766-1551
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR143360363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402464800Medicaid
MD463350400Medicaid
MD463350400Medicaid
MD402464800Medicaid
MDP62941Medicare UPIN